TABLE OF CONTENTS. Section 7: Member Eligibility... 35

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2 TABLE OF CONTENTS Sectin 1: Intrductin... 1 A. Overview: Blue Crss Cmplete... 1 B. Hw t use this manual... 2 C. Other electrnic resurces fr prviders... 3 D. Prvider cmmunicatins... 4 E. Assistance in wrking with Blue Crss Cmplete... 5 Sectin 2: System f Managed Care... 6 A. Blue Crss Cmplete prvider netwrk... 6 B. Rle/respnsibilities f practitiners... 9 C. General respnsibilities f all cntracted prviders D. Respnsibilities f hspital/ancillary prviders E. Prvider terminatin F. Blue Crss Cmplete s cmmitment t prviders G. Obligatins f recipients f federal funds H. Electrnic health recrds Sectin 3: Clinical Practice and Preventive Care Guidelines A. Abut the guidelines B. Reprting bld lead tests C. Other applicable guidelines Sectin 4: Managing the Quality f Care A. Mnitring the quality f care B. Peer review prcess C. Disciplinary actin r terminatin D. Appealing physician discipline r terminatin E. Facility nsite reviews Sectin 5: Standards and Ratings A. Access t appintments B. Waiting rm time C. Access t after-hurs care D. CAHPS survey Sectin 6: Multicultural Health Care A. Accmmdating prviders and members needs B. Aspects f culturally cmpetent care C. Enhancing cultural cmpetency in health care settings Sectin 7: Member Eligibility ii

3 A. Membership ID cards B. Checking member eligibility C. Member eligibility data files D. Member eligibility, enrllment, disenrllment, effective date E. Dual-eligible members Sectin 8: Member Benefits A. Blue Crss Cmplete primary care physician services B. Blue Crss Cmplete benefits C. Care within Michigan utside the service area D. Blue Crss Cmplete member rights and respnsibilities Sectin 9: Managing Nncmpliant Care A. Assisting practitiners in managing nncmpliant care B. Special disenrllment frm the Medicaid Health Plan Sectin 10: Managing Utilizatin A. Review f services B. Guidelines fr authrizatin C. Appealing authrizatin decisins D. Utilizatin mnitring Sectin 11: Managing Care A. Managing members with an integrated apprach B. Cllabratin with practitiners C. Pregnancy resurces D. Rapid Respnse and Outreach Team E. Children s Special Health Care Services F. Immunizatins G. Nurse Help line (fr members) Sectin 12: Pharmacy Services A. Prescriptin drug prgram verview B. Drug authrizatin guidelines C. Appealing a decisin t deny authrizatin f drugs D. Drug exclusins E. Additinal pharmacy infrmatin Sectin 13: Claims A. Claims verview B. General guidelines fr filing claims C. Filing claims electrnically D. Filing paper claims E. Prcessing submitted claims iii

4 F. Billing labratry services G. Required reprting f events I. Other guidelines fr submitting claims J. Appealing claim denials K. Crdinatin f benefits and subrgatin Sectin 14: Electrnic Funds Transfer A. Blue Crss Cmplete uses Change Healthcare fr Electrnic Funds Transfer B. Benefits f Electrnic Funds Transfer C. Prviders receive electrnic remittance advice statements D. Hw t arrange fr Electrnic Funds Transfer Sectin 15: Health Care Fraud, Waste and Abuse A. What is health care fraud? B. What is health care waste? C. What is health care abuse? D. Fraud, abuse and the Special Investigatins Unit E. Waste identificatin and recveries F. False Claims Act G. Hw t reprt health care fraud Blue Crss Cmplete has prduced this dcument in accrdance with guidelines, plicies and prcedures current with the date nted n this page. Blue Crss Cmplete reserves the right t update, mdify, change r replace any prtin f this dcument t reflect later guidelines, plicies r prcedures. The manual is an extensin f the prvider cntracts. Nthing in it is intended r shuld be understd t mdify the requirements, limitatins and/r exclusins in the prvider cntracts. This manual is the prperty f Blue Crss Cmplete and is fr use slely in yur capacity as a participating prvider. Duplicatin is limited t yur ffice staff nly. Disclsure t unauthrized persns r use fr any ther purpse is strictly prhibited. Any vilatin f the abve will be dealt with t the full extent f applicable laws. Federal law prvides severe civil and criminal penalties fr the unauthrized reprductin and distributin f cpyrighted materials. Blue Crss, Blue Care Netwrk and Blue Crss Cmplete maintain bcbsm.cm, MiBlueCrssCmplete.cm and theunadvertisedbrand.cm. The Blues d nt cntrl any ther websites referenced in this publicatin r endrse their general cntent Blue Crss Cmplete. All rights reserved. Blue Crss Cmplete f Michigan is cntracted by the Michigan Department f Health and Human Services t prvide health care cverage t eligible Medicaid beneficiaries. Blue Crss Cmplete arranges fr the prvisin f cmprehensive and cst-effective cverage t Medicaid members in 32 cunties in Michigan. NCQA is a private, nnprfit rganizatin dedicated t imprving health care quality. HEDIS is a registered trademark f the Natinal Cmmittee fr Quality Assurance. Cnsumer Assessment f Healthcare Prviders and Systems (CAHPS ) is a registered trademark f the Agency fr Healthcare Research and Quality (AHRQ). CPT is cpyright 2015 American Medical Assciatin (AMA). All Rights Reserved. N fee schedules, basic units, relative values r related listings are included in CPT. The AMA assumes n liability fr the data cntained herein. Applicable FARS/DFARS restrictins apply t gvernment use. JANUARY 2016 NOTE: Changes t the Blue Crss Manual ccurring since the previus versin are marked with a Blue Dt explained in the list f Blue Dt Changes t the Blue Crss Cmplete Prvider Manual, available at MiBlueCrssCmplete.cm/prviders. and are iv

5 Sectin 1: Intrductin SECTION 1: INTRODUCTION A. Overview: Blue Crss Cmplete What is Blue Crss Cmplete? Blue Crss Cmplete f Michigan is an independent licensee f the Blue Crss and Blue Shield Assciatin. It is a health maintenance rganizatin and is a jint venture between Blue Crss Blue Shield f Michigan and AmeriHealth Caritas Family f Cmpanies. Blue Crss Cmplete is nt cntracting as the agent f the Assciatin. N persn, entity r rganizatin ther than Blue Crss Cmplete will be held accuntable r liable fr any f Blue Crss Cmplete s bligatins created under the cntract. Blue Crss Cmplete is slely respnsible fr its wn debts and ther bligatins. Blue Crss Cmplete is cntracted with the Michigan Department f Health and Human Services t prvide health care cverage t eligible Medicaid beneficiaries. Nte: Effective April 1, 2014, Blue Crss Cmplete enrlls eligible individuals int the Healthy Michigan Plan, which ffers health care cverage t an expanded pl f Medicaid beneficiaries. This includes Adult Benefit Waiver beneficiaries. Prviders may access additinal infrmatin abut wh is eligible fr this plan at michigan.gv/healthymichiganplan > Healthy Michigan Plan Frequently Asked Questins. Click Eligibility. Blue Crss Cmplete prvides administrative services and arranges fr the prvisin f cvered services t all Blue Crss Cmplete members within the Blue Crss Cmplete service area. Blue Crss Cmplete prviders ffer preventive and wellness care (fr example, an annual physical exam) and Blue Crss Cmplete encurages the Medicaid ppulatin t use medical services fr preventive care. Blue Crss Cmplete, nt Medicaid, is the payer fr cvered health services rendered t a Blue Crss Cmplete member. Payments shall be made in accrdance with the terms f the agreement between Blue Crss Cmplete and MDHHS. What Blue Crss Cmplete des Blue Crss Cmplete f Michigan is a Medicaid managed care plan that cntracts with physicians, hspitals and ther health care prviders t deliver care and prvide service t Blue Crss Cmplete members. In additin t prviding basic health care cverage and custmer services, Blue Crss Cmplete helps prmte the delivery f high-quality care in a cst-effective manner by supprting the effrts f Blue Crss Cmplete-affiliated prviders with prgrams such as care management and chrnic cnditin management. Blue Crss Cmplete gegraphic area Blue Crss Cmplete services members in Michigan, in the fllwing 32 cunties: Allegan Hillsdale Kent Macmb Muskegn Ottawa Washtenaw Barry Hurn Lake Masn Newayg Sanilac Wayne Clintn Ingham Lapeer Mecsta Oakland Shiawassee Eatn Inia Lenawee Mnre Oceana St. Clair Genesee Jacksn Livingstn Mntcalm Oscela Tuscla 1

6 Blue Crss Cmplete missin Sectin 1: Intrductin In supprt f the Blue Crss Blue Shield f Michigan missin t ffer access t health care cverage t everyne regardless f circumstance, Blue Crss Cmplete will excel in prviding health care cverage t Medicaid beneficiaries. Blue Crss Cmplete s cmmitment t this ppulatin is demnstrated by the prvisin f cmprehensive and cst-effective cverage by Michigan s leading health insurance cmpany. Blue Crss Cmplete values Blue Crss Cmplete s values are: Integrity and hnesty Family and persnal life Persnal accuntability and empwerment Helping and caring Quality and excellence Diversity and inclusiveness Cmmunity invlvement Blue Crss Cmplete cnfidentiality standards Blue Crss Cmplete uphlds the right t privacy f members and prviders. All dcuments, data and knwledge f business and health care matters are maintained in a cnfidential manner, and strict standards are adhered t cncerning the release f member r prvider recrds and infrmatin. Blue Crss Cmplete emplyees may nt discuss these matters with anyne utside the rganizatin, except as may be required in the nrmal curse f business, with apprpriate authrizatin, r by law. Blue Crss Cmplete educates members Because knwledge is an imprtant part f preventin, member educatin is vital t the Blue Crss Cmplete system f managed care. Blue Crss Cmplete educates members abut managed care philsphy and health-related issues in varius ways: Thrugh MiBlueCrssCmplete.cm, members can access valuable health infrmatin. My Blue Health newsletter, sent three times a year, cntains infrmatin abut benefits, advice n healthy self-care practices and the latest news abut Blue Crss Cmplete prgrams. B. Hw t use this manual Hw t search the Blue Crss Cmplete Prvider Manual T search the manual, prviders shuld cmplete the fllwing steps: 1. Open the manual. 2. In the Edit menu, select Search r Find. 3. Enter the wrd r phrase that is being searched fr. 4. Press Enter. Blue Dt changes identify revisins t the manual Significant revisins t the Blue Crss Cmplete Prvider Manual are identified n the affected pages by means f a Blue Dt. A cumulative list f all Blue Dt changes made during the year is available n MiBlueCrssCmplete.cm/prviders. 2

7 Sectin 1: Intrductin Each January, a new editin f the Blue Crss Cmplete Prvider Manual is published. In the new editin, all Blue Dt changes frm the previus year are incrprated int the manual and are n lnger visible as Blue Dt changes. New Blue Dt changes are added t the new editin during the upcming year. Prviders shuld watch fr manual revisins and read the Cmplete Update and the Blue Crss Cmplete Prvider News, fr the latest infrmatin. C. Other electrnic resurces fr prviders Blue Crss Cmplete s electrnic systems Prviders are encuraged t use Blue Crss Cmplete s electrnic systems t d business with Blue Crss Cmplete. Prviders can sign up fr access t the fllwing electrnic systems: NaviNet, Blue Crss Cmplete s secure prvider prtal. Prviders can use NaviNet t: Verify a member s eligibility and benefits and see the histry Access the primary care prvider panel rster and ther reprts Check the status f claims Submit and check the status f authrizatin requests Access Care Gap reprts fr medical and pharmacy services Prviders wh are nt already NaviNet users can sign up at NaviNet.net > Sign up. web-denis, the Blue Crss user-friendly electrnic inquiry tl. Prviders can use web-denis t: Verify a member s eligibility Lcate a Remittance Advice Prviders can sign up fr Prvider Secured Services and web-denis at bcbsm.cm/prviders > Help Center > Hw t sign up fr Prvider Secured Services, r call BLUE-WEB ( ). Nte: Prviders must use their user ID within 14 days after they receive it. After that, prviders are encuraged t lg in t Prvider Secured Services n a mnthly basis. Prviders must lg in at least nce every six mnths t keep their accunt active. If the accunt becmes disabled r is n lnger active, prviders shuld call the Web Supprt Help Desk at t reactivate their accunt. Blue Crss Prvider Enrllment and Change Self-Service (available nly t practice grup administratrs fr prfessinal grups and allied prviders) Prviders can als access additinal infrmatin n Blue Crss Cmplete s public website at MiBlueCrssCmplete.cm/prviders. Other resurces n the Web Prviders can als access the fllwing resurces nline at MiBlueCrssCmplete.cm/prviders: Blue Crss Cmplete Prvider Manual Blue Crss Cmplete Prvider Resurce Guide At-a-Glance, a quick reference fr phne and fax numbers Blue Crss Cmplete Prvider Newsletter - Cnnectins Cmplete Update, a bi-mnthly publicatin that ffers summaries f current Blue Crss Cmplete infrmatin Each f these resurces is an imprtant surce f infrmatin abut ding business with Blue Crss Cmplete. 3

8 Frms 4 Sectin 1: Intrductin Prviders can access Blue Crss Cmplete frms at MiBlueCrssCmplete.cm/prviders. The electrnic versin f a frm can be saved t a cmputer hard drive and printed. The frms are pened with Adbe Reader. A free cpy f Adbe Reader is available at get.adbe.cm/reader. Prviders wh use the frms they dwnlad ver time shuld check back peridically t make sure they have the latest versin f the frm. They shuld use the effective date r revisin date f the frm t determine whether they have the mst current versin. These dates are typically shwn at the lwer right n each page f the frm. Fr sme f the frms, an interactive versin is available. An interactive frm can be pened using Adbe Reader versin 7.0 r later, cmpleted electrnically, saved and printed. In sme cases, the frm can als be submitted electrnically nce it has been cmpleted. D. Prvider cmmunicatins Blue Crss Cmplete prviders receive an rientatin Blue Crss Cmplete prviders receive a visit frm a prvider accunt executive wh familiarizes them with things they ll need t knw abut Blue Crss Cmplete, including the fllwing: Member ID card Checking eligibility and benefits Infrmatin abut the service area Cntact phne numbers Drug cverage Utilizatin management requirements and systems (NaviNet and Jiva TM ) Member transprtatin resurces Submitting claims Prviders receive infrmatin in ther ways Prviders als receive updates n Blue Crss Cmplete infrmatin thrugh the fllwing: NaviNet web-denis (Direct Eligibility Netwrk Infrmatin System) messages Blue Crss Cmplete Prvider Manual Blue Crss Cmplete Prvider Newsletter - Cnnectins Cmplete Update, a ne-page summary f infrmatin pertinent t Blue Crss Cmplete prviders published every ther mnth Training fr prviders and their ffice staff by prvider accunt executives Prviders can cntact Prvider Inquiry Prviders can cntact Blue Crss Cmplete Prvider Inquiry fr assistance. Blue Crss Cmplete Prvider Inquiry hurs are 8 a.m. t 5 p.m., Mnday thrugh Friday. The Blue Crss Cmplete Prvider Inquiry phne and fax numbers are: Phne: Fax:

9 Sectin 1: Intrductin Prviders shuld be ready t supply the fllwing infrmatin when calling Prvider Inquiry: Caller s name and direct phne number Prvider s NPI Member s cntract number, name and date f birth The infrmatin being requested E. Assistance in wrking with Blue Crss Cmplete Prviders can request assistance thrugh Prvider Outreach Prviders may request individual assistance by calling their Blue Crss Cmplete prvider accunt executive. The Blue Crss Cmplete prvider accunt executive can help with the fllwing: Enrllment and credentialing questins Cntractual issues Recurring r unreslved prblems Educatin and training n Blue Crss Cmplete plicies, prcedures and prgrams Discussin f medical care grup administratin Changes in primary care physician acceptance cdes Requests fr cverage / n-call prviders 5

10 Sectin 2: System f Managed Care SECTION 2: SYSTEM OF MANAGED CARE A. Blue Crss Cmplete prvider netwrk What is the Blue Crss Cmplete prvider netwrk? The Blue Crss Cmplete prvider netwrk includes primary care physicians, specialists, hspitals and prviders wh are licensed r certified by the state f Michigan and authrized t prvide Medicaid health care services. Prviders wh wish t enrll in the Blue Crss Cmplete prvider netwrk shuld cmplete the apprpriate Blue Crss Cmplete enrllment frm (fr practitiners r facilities), lcated at MiBlueCrssCmplete.cm/prviders, under the Change and Enrllment Frms heading. Submit the frm accrding t the instructins utlined n the frm. Prviders may call Blue Crss Cmplete Prvider Inquiry at with any questins. Prviders wh have questins abut affiliatin with Blue Crss Cmplete r abut crdinating the care f a patient within the Blue Crss Cmplete netwrk shuld cntact their prvider accunt executive. Hw t access infrmatin abut the Blue Crss Cmplete prvider netwrk Infrmatin n all prviders in the Blue Crss Cmplete prvider netwrk can be accessed thrugh the fllwing: The nline Blue Crss Cmplete prvider search at MiBlueCrssCmplete.cm > Find a Prvider. Blue Crss Cmplete Prvider Inquiry at between 8 a.m. and 5 p.m., Mnday thrugh Friday Mental health services are prvided thrugh the netwrk Mental health services are prvided thrugh the Blue Crss Cmplete mental health prvider netwrk. Nte: Treatment fr substance use disrders is nt cvered by Blue Crss Cmplete. Members must cntact the Substance use Disrder Crdinating Agency fr their cunty. Blue Crss Cmplete cvers unlimited utpatient mild t mderate mental health interventin services and treatment. There are n referrals r authrizatins required. Members wh have severe and persistent mental illness shuld cntact their lcal PHIP in their cunty lcated at Michigan.gv/mdhhs. Nte: The Michigan Department f Health and Human Services has made available a standard cnsent frm fr sharing behaviral health and substance abuse treatment infrmatin. Here is sme additinal infrmatin abut this frm: The frm cmplies with Public Act 129 f Althugh prviders are nt required t use this frm, they are required t accept it. Prviders shuld visit michigan.gv/bhcnsent t access the DCH-3927 behaviral health cnsent frm and t read mre abut it. PerfrmRx is the pharmacy benefit manager PerfrmRx, the pharmacy benefit manager fr Blue Crss Cmplete: Prcesses prescriptin claims Manages the Blue Crss Cmplete Clinical Pharmacy Help Desk 6

11 Prvides cverage reviews fr prir authrizatin after nrmal business hurs Prvides specialty pharmacy services Sectin 2: System f Managed Care Preferred vendrs fr utpatient labratry services, DME and diabetic supplies The table belw shws the vendrs preferred by Blue Crss Cmplete that prvide cvered services invlving utpatient labratry services; durable medical equipment / prsthetics and rthtics; and diabetic supplies fr prviders affiliated with Blue Crss Cmplete. Type f service (utpatient) Labratry Preferred vendrs JVHL, which prvides the statewide netwrk and third-party administratin fr utpatient labratry services. Prviders shuld refer t the Blue Crss Cmplete claims prcessing sectin f this manual fr infrmatin n billable in-ffice labratry prcedures and guidelines fr submitting claims fr exclusins t the JVHL labratry management agreement. Quest Diagnstics, prvides statewide netwrk and third-party administratin fr utpatient labratry services. Prviders shuld refer t the Blue Crss Cmplete claims prcessing sectin f this manual fr infrmatin n billable in-ffice labratry prcedures and guidelines fr submitting claims fr exclusins t Quest Diagnstic management agreement. DME, P&O and nndiabetic medical supplies Diabetic and incntinence supplies Nrthwd, Inc., which prvides the statewide netwrk and third-party administratin fr mst DME and P&O cvered services and is cntracted by Blue Crss Cmplete t authrize and pay fr all DME and P&O cvered services Nte: As a general rule, utpatient diabetic supplies are nt prvided thrugh the Nrthwd netwrk. J&B Medical Supply, which prvides the statewide netwrk fr utpatient diabetic supplies Prviders shuld use Blue Crss Cmplete s preferred nly vendrs, when pssible Here are Blue Crss Cmplete s guidelines related t vendrs: Prviders shuld use Blue Crss Cmplete s preferred vendrs, when pssible. When a preferred vendr is nt available, prviders shuld use anther vendr that is cntracted with Blue Crss Cmplete. Prviders shuld refrain frm referring members t vendr prviders wh are nt cntracted with Blue Crss Cmplete, including thse wh perate exclusively utside f Michigan. Prviders wh feel that a Blue Crss Cmplete-cntracted vendr cannt meet a need shuld cntact the vendr r call the Blue Crss Cmplete Utilizatin Management department at (press 1) t submit a request fr a service prvided by a nncntracted vendr. This shuld ccur prir t the service being rendered, unless it is an emergency. Members may arrange fr transprtatin Blue Crss Cmplete members may arrange fr transprtatin fr medically necessary medical exams and treatment, including picking up prescriptins and durable medical equipment. Members shuld call t arrange transprtatin. (TTY users shuld call ) Members shuld call t arrange transprtatin in advance f their appintment. They can cnsult their Blue Crss Cmplete Member Handbk fr mre specific infrmatin n this requirement. 7

12 Sectin 2: System f Managed Care Additinal infrmatin n transprtatin services fr Blue Crss Cmplete members is fund at the fllwing lcatins: MiBlueCrssCmplete.cm > Resurces > Transprtatin Services In the brchure We can help yu get there Nte: Dual-eligible members wh have transprtatin benefits thrugh bth BCN Advantage and Blue Crss Cmplete shuld exhaust their BCN Advantage benefit befre arranging transprtatin under their Blue Crss Cmplete benefit. Members living in Wayne Cunty wh need transprtatin fr dental care, substance abuse services, sme types f mental health services and ther services prvided by the state f Michigan shuld call LgistiCare at between 8 a.m. and 5 p.m. Mnday thrugh Friday. Specialty care services d nt require authrizatin Blue Crss Cmplete members may access specialty care services withut an authrizatin frm prviders affiliated with Blue Crss Cmplete. Services rendered by prviders nt affiliated with Blue Crss Cmplete, including thse utside the state f Michigan, must be preauthrized by calling (press 1). Specialty netwrk access The Michigan Department f Health and Human Services, the Michigan Medicaid health plans and several public entities have wrked n a jint initiative t increase access t specialty care services t Michigan Medicaid recipients. Blue Crss Cmplete des ffer a cmprehensive prvider netwrk, but shuld a prvider determine an in-netwrk specialist is unavailable, the prvider can request a referral t access a specialty care prvider affiliated with ne f the public entities Blue Crss Cmplete des nt cntract with (Central Michigan University and Western Michigan University). The fllwing table shws the hspital systems that wuld require authrizatin befre a member is seen there. Public entity Hspital system Central Michigan University Cvenant Healthcare St. Mary s f Michigan Western Michigan University Brgess Health T request assistance with btaining an authrizatin, prviders can cntact Blue Crss Cmplete s Utilizatin Management department at (press 1). Sme services are available thrugh unique prviders Blue Crss Cmplete als cvers services prvided by unique prviders, such as fr services frm Federally Qualified Health Centers, Rural Health Clinics, lcal health departments, family planning clinics and child-adlescent health center services (immunizatins, etc.). Guidelines fr ut-f-state prviders Emergency services rendered by ut-f-state prviders are cvered. Other services rendered by ut-f-state prviders must be authrized by Blue Crss Cmplete prir t the service being rendered. Primary care physicians crdinate care A primary care physician is a medical dctr r a dctr f stepathic medicine licensed in the state f Michigan r a nurse practitiner r physician assistant whse practice is primarily in family practice, general practice, internal medicine, internal medicine/pediatrics r pediatrics. 8

13 9 Sectin 2: System f Managed Care The primary care physician prvides and crdinates medical care and services fr members. Members must select a participating primary care physician as sn as they jin Blue Crss Cmplete. Members can use the nline prvider search t find a physician. These resurces prvide infrmatin n primary care physicians, specialists and ther prviders acrss the state. Every primary care physician listed in the nline search must meet Blue Crss Cmplete s affiliatin and credentialing requirements. B. Rle/respnsibilities f practitiners Primary care physician s central rle Each Blue Crss Cmplete-affiliated prvider is valued fr the key cntributins he r she makes in prviding members with the highest quality care in the mst effective manner. The primary care physician, in particular, plays a central rle. Each Blue Crss Cmplete member must select a primary care physician, but members f the same family d nt have t have the same physician. Primary care physician prvides access t care The respnsibilities f the primary care physician in prviding access t care include but are nt limited t: Prviding telephne access 24 hurs a day, seven days a week with a triage mechanism directing members t an apprpriately trained health prfessinal Accepting a minimum number f Blue Crss Cmplete members and giving 60 days written ntice f a change in acceptance status Primary care physician prvides care The primary care physician is respnsible fr prviding primary care services t members within the scpe f the physician s medical specialty, including: Office visits fr sick and well care Health maintenance exams Preventive care services Health educatin Inpatient cnsultatins Primary care physician arranges fr care frm ther prviders The primary care physician s ffice is als respnsible fr crdinating care that must be rendered thrugh ther prviders, including specialty and ancillary services in r ut f the hspital, as medically indicated. Examples include: Specialty treatment Hspitalizatin Pst-hspital care Ancillary and specialty services using Blue Crss Cmplete-cntracted vendrs Referrals t chrnic cnditin and care management prgrams Prescriptin medicatins, fllwing the Blue Crss Cmplete custm frmulary, as apprpriate Referrals t health educatin prgrams Prviding r referring fr habilitative care (nly fr Healthy Michigan Plan members)

14 Sectin 2: System f Managed Care Referring fr hearing aids (fr members under 21 with standard Blue Crss Cmplete and fr Healthy Michigan Plan members 21 and ver) Pediatric and bstetrician-gyneclgist services are accessed by Blue Crss Cmplete members withut a referral frm their primary care physician. Guidelines related t practitiners cvering fr primary care physicians The primary care physician must prvide fr member care at all times and ensure that cvering r n-call medical persnnel are f like r similar specialty and are Blue Crss Cmplete-affiliated prviders wh understand the prcedures fr managing Blue Crss Cmplete members. Specialists have respnsibilities It is the respnsibility f the specialist t: Prvide services in a manner cmmensurate with the standards f practice fr the physician s specialty Prvide a timely written reprt t the member s primary care physician fr inclusin in the member s medical recrd Use Blue Crss Cmplete-cntracted agencies and facilities fr tests r services prvided t members, except as authrized by Blue Crss Cmplete Allw primary care physicians access t the Blue Crss Cmplete member s medical recrd upn request Specialists expected t share infrmatin with primary care physician As part f Blue Crss Cmplete s cntinuing cmmitment t ensure that members receive the highest quality and safest care pssible, specialists, including OB/GYNs and behaviral health practitiners, are expected t share members clinical infrmatin with members primary care physicians. Blue Crss Cmplete medical recrd standards and Natinal Cmmittee fr Quality Assurance standards require evidence f cntinuity and crdinatin f care. In additin, prvider cntracts specify that the specialist s timely cmmunicatin with the referring physician is essential t effectively manage the member s care. This requires prviding infrmatin t the member s PCP abut the episdes f care rendered in different settings. Dcumentatin shuld be sent t and received by the primary care physician within 30 days f service. Nte: Behaviral health specialists are permitted by law t share behaviral health infrmatin withut signed written cnsent frm the member. A signed written cnsent frm the member is required by law befre the release f infrmatin related t the treatment f substance abuse r HIV. Guidelines related t practitiners cvering fr specialists It is the respnsibility f the specialist t prvide fr member care at all times and ensure that cvering r n-call medical persnnel are f like r similar specialty and are Blue Crss Cmplete-affiliated prviders wh understand the prcedures fr managing Blue Crss Cmplete members. C. General respnsibilities f all cntracted prviders General respnsibilities f all prviders wh cntract with Blue Crss Cmplete Prviders wh affiliate with Blue Crss Cmplete sign an applicable prvider agreement that utlines their respnsibilities. The fllwing is a summary f what Blue Crss Cmplete expects frm cntracted prviders: 10

15 Sectin 2: System f Managed Care Nte: This summary applies t all prviders, including primary care physicians, specialists and hspital and ancillary prviders. Prviders will cperate with all Blue Crss Cmplete prgrams as utlined in the Blue Crss Cmplete Prvider Manual and Blue Crss Cmplete plicies. Prviders will cmply with applicable authrizatin prcedures set frth by Blue Crss Cmplete fr the validatin and payment f cvered services. Prviders are respnsible fr verifying the current and prper authrizatin f all nnemergency services prir t prviding such services. Prviders will seek apprpriate authrizatin fr any prpsed additinal services r fr services fr which the initial authrizatin perid has expired at the time f service. Physicians will utilize Blue Crss Cmplete s netwrk f cntracted prviders unless services cannt be prvided by the in-netwrk prviders. Prviders will maintain adequate medical and general liability cverage as prescribed in each prvider s Blue Crss Cmplete affiliatin agreement and all licenses, certificatins, accreditatins and practice privileges required by law. Prviders will furnish prf f such credentials upn Blue Crss Cmplete request. Prviders will fully cmply with applicable Blue Crss Cmplete credentialing requirements and will immediately ntify Blue Crss Cmplete f any material changes in the prvider s licensure, certificatin, accreditatin r practice privileges. Prviders will furnish cvered services in accrdance with each prvider s legal qualificatins and prfessinal capabilities in a manner cnsistent with prfessinally recgnized standards f health care. Prviders must prvide all identifying infrmatin (phne numbers, grup affiliatins, Natinal Prvider Identifier, tax identificatin number, billing address, etc.). When that infrmatin changes, prviders must update the infrmatin at least 60 days in advance f the change, when pssible. This als applies t infrmatin abut changes in physician staffing; after-hurs and vacatin cverage; and practice lcatins. This als applies t ther types f changes. Nte: Changes shuld be submitted using the Blue Crss Cmplete Prvider Change Frm, lcated at MiBlueCrssCmplete.cm/prviders, under the Change and Enrllment Frms heading. Submit the frm accrding t the instructins utlined n the frm. Prviders may call Blue Crss Cmplete Prvider Inquiry at with any questins. Prviders will treat Blue Crss Cmplete members in the same manner and with the same quality and prmptness as ther patients are treated. In prviding cvered services, prviders will refrain frm discriminating against any Blue Crss Cmplete member n the basis f his r her Blue Crss Cmplete membership, surce f payment, sex, ethnicity, age, race, clr, religin, natinal rigin, ancestry, marital status, sexual preference r any factr related t health status, including but nt limited t medical cnditin (including cnditins arising ut f dmestic vilence), claims experience, receipt f health care, medical histry, genetic infrmatin, evidence f insurability, disability r handicap, r any ther basis prhibited by federal law. Prviders will lk slely t Blue Crss Cmplete fr payment f cvered services and will accept Blue Crss Cmplete payment as payment in full fr all cvered services. The nly exceptin is that prviders will pursue payments frm ther respnsible payers when apprpriate. Prviders will maintain accurate and timely medical recrds fr Blue Crss Cmplete members fr at least ten years in accrdance with all federal and state laws, ensure the cnfidentiality f thse recrds and affrd access t thse recrds by authrized Blue Crss Cmplete representatives, peer reviewers and gvernment representatives upn request. Prviders will, t the extent pssible, cmply with federal standards designed t prmte the use f health infrmatin technlgy. Prviders will allw Blue Crss Cmplete t use prvider perfrmance data fr quality imprvement activities. Prviders will submit claims fr cvered services in accrdance with Blue Crss Cmplete-specified frmats and using Blue Crss Cmplete-designated claim frms and the prvider s NPI. 11

16 12 Sectin 2: System f Managed Care Prviders will cmply with all applicable state and federal legislative, regulatry and legal requirements. Other than the apprpriate discharge f a patient, prviders are expected t refrain frm withhlding care, appintment access, medicatin, prescriptins r treatment f any kind r fr any reasn. Prviders will cmply with and adhere t the American Medical Assciatin Principles f Medical Ethics (Cde f Medical Ethics and Cnduct) in the care and treatment f Blue Crss Cmplete patients. Neither Blue Crss Cmplete nr its prviders shall use any financial incentive r accept any reimbursement that either directly r indirectly is an inducement t deny, reduce, limit r delay specific medically necessary and apprpriate services. Prviders will cmply with all bligatins utlined in their prvider cntracts and in the amendments t thse cntracts. Physicians expected t cmply with AMA Cde f Medical Ethics Blue Crss Cmplete expects physicians t cmply with the American Medical Assciatin Cde f Medical Ethics, which encurages physicians t select a persnal physician fr their regular health care and refrain frm treating themselves r their immediate family members. In additin, physicians shall nt bill Blue Crss Cmplete fr cvered services prvided t themselves r t their immediate family members. The fllwing Blue Crss Cmplete Quality Management plicies and prcedures als apply: Practitiners fund t have selected themselves as their wn primary care physician r as the primary care physician fr their immediate family members are ntified that they are nt eligible t d s and are asked t select anther apprpriately qualified practitiner. If the practitiner fails t select anther apprpriately qualified practitiner, Blue Crss Cmplete will make the reassignment. Practitiners wh have prvided billable medical services t themselves r t their immediate family members will be ntified that they are nt eligible t d s and will be asked t select anther apprpriately qualified practitiner fr medical services. Practitiners wh have prvided billable medical services fr themselves r fr their immediate family members will be cntacted by Blue Crss Cmplete s reginal chief medical fficer r his r her designee. These activities are tracked in accrdance with Blue Crss Cmplete s Quality Management plicies and prcedures. D. Respnsibilities f hspital/ancillary prviders Respnsibilities f hspital and ancillary prviders It is the respnsibility f hspital and ancillary prviders t: Accept Blue Crss Cmplete members and, except in emergencies, prvide nly authrized services Crdinate with the member s primary care physician r with Blue Crss Cmplete, if necessary, in the fllwing situatins: When additinal treatment r tests are needed When the treatment will exceed the dates n the initial authrizatin Use Blue Crss Cmplete-affiliated prviders and facilities fr tests r services prvided t members unless services cannt be prvided by in-netwrk prviders

17 Sectin 2: System f Managed Care E. Prvider terminatin Blue Crss Cmplete ntifies members when a prvider terminates When a primary care physician stps affiliating with Blue Crss Cmplete fr any reasn, Blue Crss Cmplete will endeavr t prvide timely written ntice f the physician s terminatin t all f the physician s members within 30 days f the date f ntificatin. If the terminating prvider is a primary care physician, all members assigned t that physician will receive written ntificatin. If the terminating prvider is a specialty care prvider, members with a recent claim with that prvider will receive written ntificatin. Prviders wishing t terminate must ntify Blue Crss Cmplete Prviders are required under their affiliatin agreements t prvide written ntificatin 60 days in advance t Blue Crss Cmplete when they wish t terminate their Blue Crss Cmplete prvider affiliatin. Prviders must terminate their Blue Crss Cmplete affiliatin in accrdance with the terms and cnditins f their prvider agreement and cntinue t prvide cvered services t members. Prviders shuld refer t their cntract fr the prper ntificatin time perid and any additinal requirements fr terminatin. Timely ntificatin f prvider terminatin assures prper payment t prviders and assures cntinuity f care fr Blue Crss Cmplete members. Prviders are reminded that timely ntificatin t the members is facilitated by the ntificatin that prviders must give t Blue Crss Cmplete. Blue Crss Cmplete assigns a new primary care physician Blue Crss Cmplete ntifies members f their primary care physician terminatin and assigns a new primary care physician. Members can call Blue Crss Cmplete Custmer Service at between 8 a.m. and 7 p.m. Mnday thrugh Friday, t change their primary care physician if they s chse. (TTY users shuld call ) Members receive additinal infrmatin frm Blue Crss Cmplete t assist them in the transitin, if the Blue Crss Cmplete netwrk is mdified. Members wh are pregnant r have a terminal illness and wh want t cntinue their care with their current prvider, even thugh the prvider has terminated his r her Blue Crss Cmplete affiliatin, shuld cntact Blue Crss Cmplete Custmer Service. Blue Crss Cmplete ntifies members when a specialist terminates When a specialist r specialty grup has requested terminatin f Blue Crss Cmplete affiliatin, Blue Crss Cmplete ntifies the affected members abut the terminatin and will assist affected members in transferring t the care f anther affiliated prvider. Blue Crss Cmplete will infrm affected members f the financial cnsequences f cntinuing care with the prvider after disaffiliatin specifically, that althugh the prvider cannt bill the members, the members als cannt cntinue t see a nnparticipating prvider. Affected members are thse members wh have been under the nging care f the specialist r specialty grup. Nte: Members may cntinue t see disaffiliated prviders in certain circumstances. As part f the prcess, the Blue Crss Cmplete care manager als wrks with the member s primary care physician t arrange fr new referrals. 13

18 Sectin 2: System f Managed Care The prvider is expected t ntify any Blue Crss Cmplete member wh seeks services after the terminatin that the prvider is n lnger affiliated with Blue Crss Cmplete. Where t submit terminatin ntices Terminatin ntices shuld be submitted in accrdance with the ntice requirements f the prvider agreement. Prviders shuld submit terminatin ntices fr Blue Crss Cmplete t: Directr, Prvider Netwrk Management Blue Crss Cmplete 100 Galleria Officentre Suite 210 Suthfield, MI F. Blue Crss Cmplete s cmmitment t prviders What prviders can expect frm Blue Crss Cmplete Primary care and specialty physicians and hspital and ancillary prviders can expect Blue Crss Cmplete t: Prcess and pay claims fr cvered and authrized services in a timely fashin and in accrdance with state and federal law Prvide active quality management, utilizatin management and care management prgrams Maintain a credentialing prgram fr prviders Respnd t prvider inquiries in a timely manner Infrm prviders abut changes t Blue Crss Cmplete s prgrams, plicies and prcedures in a timely manner Infrm prviders abut hw Blue Crss Cmplete crdinates interventins with treatment plans fr individual members Infrm prviders abut hw t cntact the Blue Crss Cmplete staff respnsible fr prviding care management services t members Supprt prviders t make decisins interactively with members regarding their health care Treat prviders with curtesy and respect Infrm prviders abut hw t cmmunicate cmplaints regarding Blue Crss Cmplete s prgrams, services and staff Carry ut ther respnsibilities as utlined in the prvider cntracts and in the amendments t thse cntracts. Prcesses fr appeals r cmplaints Blue Crss Cmplete has specific appeal prcesses fr prviders wh disagree with a decisin regarding credentialing, quality cncerns, pharmacy, care management r claims. These prcesses are described as fllws: Fr infrmatin n credentialing prcesses, g t (Prvider Secured Services) web-denis > BCN Prvider Publicatins and Resurces > Prvider Manual > Affiliatin (under BCN Prvider Manual chapters) Fr infrmatin n addressing quality cncerns, see the Mnitring quality f care sectin f this manual. 14

19 Sectin 2: System f Managed Care Fr infrmatin abut appealing decisins n authrizatin requests related t medicatins, see the Pharmacy Services sectin f this manual. Fr infrmatin n appealing claims denials, see the Blue Crss Cmplete claims prcessing sectin f this manual. Fr infrmatin abut appeals related t the temprary increased payment rate fr primary care services, see the Blue Crss Cmplete claims prcessing sectin f this manual. Prviders wh have a general cmplaint regarding Blue Crss Cmplete prgrams, services r staff shuld cntact the apprpriate Blue Crss Cmplete prvider accunt executive. Credentialing Healthcare prfessinal and prvider rights Healthcare prfessinal and prviders have the right t: Review infrmatin btained thrugh primary surce verificatin fr credentialing purpses. This includes infrmatin frm malpractice insurance carriers and state licensing bards. This des nt include infrmatin cllected frm references, recmmendatins and ther peer review prtected infrmatin. Be ntified if any credential infrmatin is received that varies substantially frm applicatin infrmatin submitted by the health care prfessinal r prvider: (actins n license, malpractice claim histry, suspensin r terminatin f hspital privileges, r bard-certificatin decisins with the exceptin f reference, recmmendatins r ther peer-review prtected infrmatin. The health care prfessinal r prvider will have the right t crrect errneus infrmatin if the credentialing infrmatin received varies substantially frm the infrmatin that was submitted n his r her applicatin. Upn request, be infrmed f the status f their applicatin if applicatin is current and cmplete, the applicant can be infrmed f the tentative date that his r her applicatin will be presented t the Credentialing Cmmittee fr apprval. G. Obligatins f recipients f federal funds Prviders bliged t cmply with requirements Prviders affiliated with Blue Crss Cmplete are paid fr their services with federal funds and must cmply with all requirements f laws applicable t recipients f federal funds, including Title VI f the Civil Rights Act f 1964, the Rehabilitatin Act f 1973, the Age Discriminatin Act f 1975 and the Americans with Disabilities Act f Blue Crss Cmplete is prhibited frm issuing payment t a prvider r entity that is debarred frm any federal r state agency. T cmply with this requirement, Blue Crss Cmplete will nt issue payment t any prvider wh appears in any f the fllwing lists: Scial Security Administratin s Death Master File Natinal Plan and Prvider Enumeratin System List f Excluded Individuals/Entities (LEIE) System fr Award Management (SAM) Medicare Exclusin Database MDHHS /Medical Services Administratin Sanctined Prvider List Licensing and Regulatry Affairs Disciplinary Actin Reprts A pssible exceptin t this prhibitin is payment fr emergency services under certain circumstances. 15

20 16 Sectin 2: System f Managed Care In additin, prviders are prhibited frm emplying directrs, fficers, managing partners, agents, emplyees r persns with beneficial wnership f mre than 5 percent wh appear n any f these databases. Prviders must check the databases when hiring and must als check their staff against the LEIE and SAM n less frequently than mnthly. A cde f cnduct, as referred t by CMS guidelines, is a set f values and ethical standards that bth Blue Crss Cmplete and prviders shuld adhere t in rder t prevent, stp r crrect nncmpliance. Prviders are expected t adhere t the Blue Crss Cmplete cde f cnduct and als t create ne fr their ffice that best fits the culture in their ffice. The cde f cnduct shuld be a written dcument, easily accessible by emplyees. Effective lines f cmmunicatin CMS emphasizes the imprtance f pen and effective lines f cmmunicatin as an integral part f a cmpliance prgram. Having effective lines f cmmunicatin means that Blue Crss Cmplete, prviders, and their emplyees are made aware f the fllwing thrugh training and management: What is expected f them regarding ethics and cmpliance based n the cde f cnduct That cmpliance is everyne s respnsibility Hw t reprt instances f suspected fraud, waste, abuse and nncmpliance It is imprtant that emplyees are cmfrtable with reprting nncmpliant activities within their wn rganizatins. CMS emphasizes that effective cmmunicatin nt nly means that emplyees may reprt nncmpliant activities annymusly, but als that emplyees understand they are legally prtected frm retaliatin when they reprt suspected nncmpliance in gd faith. H. Electrnic health recrds Use electrnic health recrds Blue Crss Cmplete encurages the use f electrnic instead f paper medical recrds fr maintaining members health infrmatin. Sme advantages f electrnic health recrds are: Availability f accurate and cmplete infrmatin anytime the member presents t health care prviders t aid in diagnses and treatment Enhanced ability t crdinate a member s care amng varius health care prviders Reduced paperwrk and increased efficiency fr members and prviders Get help making the change t electrnic health recrds The Michigan Center fr Effective IT Adptin is dedicated t assisting prviders in making the transitin t electrnic health recrds. M-CEITA prvides educatin, utreach and technical assistance fr prviders in develping digitized patient infrmatin, physician rder entry and decisin supprt mechanisms. Prviders may cntact M-CEITA by telephne at MICH-EHR ( ). Prviders may access additinal infrmatin abut M-CEITA s services at mceita.rg. EHR incentive prgrams are available Infrmatin n EHR incentive prgrams is available at the fllwing lcatins: Infrmatin n prgrams ffered by the Centers fr Medicare & Medicaid Services, including a timeline fr incentive payments, is available at cms.gv > Regulatins & Guidance > EHR Incentive Prgrams. Other infrmatin is available at Electrnic Health Recrd (EHR) Incentive Prgram sectin f the General Infrmatin fr Prviders chapter f the MDHHS Medicaid Prvider Manual.

21 17 Sectin 2: System f Managed Care

22 Sectin 3: Clinical Practice and Preventive Care Guidelines Sectin 3: Clinical Practice and Preventive Care Guidelines A. Abut the guidelines Purpse f the guidelines Blue Crss Cmplete prmtes the develpment, apprval, implementatin, mnitring and revisin f unifrm evidence-based clinical practice and preventive care guidelines fr practitiners. Such guidelines prmte the delivery f quality care and reduce variability in physician practice. Evidence-based guidelines are nes that are knwn t be effective in imprving health care utcmes. All guidelines are intended as a general resurce t assist the practitiner and are nt meant as a substitute fr the practitiner s medical judgment. They are based n current medical literature, including existing guidelines and practice standards within the cmmunity. Encuraging adherence t the guidelines Adherence t the clinical practice and preventive care guidelines is encuraged by Blue Crss Cmplete. This encuragement is prvided thrugh interventins fcusing n imprving health utcmes fr Blue Crss Cmplete members, which include the fllwing: Member and prvider incentives Reminder mailings Telephne reminders Newsletter articles Educatinal materials Onging mnitring f cmpliance with the preventive health guidelines is cnducted thrugh medical recrd reviews and quality studies. B. Reprting bld lead tests Blue Crss Cmplete prviders must reprt bld lead analysis results Prviders must reprt t MDHHS the bld lead analysis results f children wh are Blue Crss Cmplete members. T view the testing plan and get additinal infrmatin abut the MDHHS lead pisning preventin prgram, prviders can: G t michigan.gv/leadsafe Call Frms related t the cllectin and submissin f bld samples and the reprting f test results are available at MiBlueCrssCmplete.cm/prviders. C. Other applicable guidelines MQIC guidelines Blue Crss Cmplete endrses the clinical practive and preventive care guidelines develped by the Michigan Quality Imprvement Cnsrtium. The guidelines are designed t imprve the cnsistent delivery f services t members and t establish a cre set f clinical practice guidelines and perfrmance measures. The MQIC guidelines can be accessed at mqic.rg > Current guidelines. 18

23 Sectin 3: Clinical Practice and Preventive Care Guidelines Nte: The MQIC guidelines can be accessed n ios and Andrid mbile devices thrugh applicatins develped by MQIC that can be fund in the Apple App Stre and at Ggle play. Blue Crss Cmplete guidelines In additin t the MQIC guidelines, Blue Crss Cmplete maintains the fllwing tw internal guidelines: Diagnsis and Management f Chrnic Obstructive Pulmnary Disease (COPD) Diagnsis and Management f Attentin Deficit Hyperactivity Disrder (ADHD) These guidelines can be accessed at MiBlueCrssCmplete.cm/prviders. 19

24 Sectin 4: Managing the Quality f Care SECTION 4: MANAGING THE QUALITY OF CARE A. Mnitring the quality f care Prviders shuld identify quality cncerns Blue Crss Cmplete encurages all areas f the crpratin as well as external surces t identify cncerns regarding quality f care r service. These quality issues are reviewed and investigated. Member satisfactin is the gal The Blue Crss Cmplete Quality Management department reviews all member reprts f quality f care issues. Quality Management staff tracks and trends quality f care cncerns. All ptential quality f care cncerns are submitted t the designated Blue Crss Cmplete chief medical fficer fr review. Blue Crss Cmplete cnducts member satisfactin surveys n varius issues, including the member s perceptin f the quality f health care prvided. Prviders ntify Blue Crss Cmplete abut quality cncerns Blue Crss Cmplete encurages all prviders t actively participate in its cntinuus quality imprvement prcess. Prviders are invited t write t Blue Crss Cmplete abut quality f care cncerns. Prviders shuld send letters t: Blue Crss Cmplete Quality Management Suite Galleria Officentre Suthfield, MI Fr additinal infrmatin, prviders can call Blue Crss Cmplete Prvider Inquiry at B. Peer review prcess Descriptin f peer review prcess Blue Crss Cmplete uses a frmal peer review prcess t evaluate a practitiner s perfrmance fr identified quality f care cncerns. The plicy applies t all affiliated Blue Crss Cmplete practitiners and independent licensed practitiners. The peer review prcess is used t identify, investigate, analyze, mnitr and reslve all ptential quality f care issues. The invlved physician is ntified when an issue is identified. Activities are cnfidential All peer review activities are cnfidential, in cmpliance with legal requirements and state statutry standards. The disseminatin f practitiner-specific infrmatin is limited t the invlved practitiner r t thse individuals wh require the data in rder t perfrm any recmmended crrective actin. Examples f quality issues The fllwing are examples f quality f care issues: Deviatins frm standards and guidelines that can be measured but have n direct impact n the practitiner/patient relatinship Deviatins frm medical practice r frm generally accepted cmmunity medical standards that have the ptential t adversely affect the member 20

25 Sectin 4: Managing the Quality f Care Substandard care that results in r has the ptential t result in a significant adverse effect n the member Steps in the peer review prcess The peer review prcess fllws these steps: Step Actin 1 The designated Blue Crss Cmplete chief medical fficer may determine that an issue exists r may ask the relevant cmmittee t determine if there is an issue. The review cmmittees may include the Blue Crss Cmplete Clinical Quality Cmmittee r the Enterprise Credentialing Cmmittee. 2 Blue Crss Cmplete sends the practitiner r independent licensed practitiner a certified letter t advise the practitiner f the ptential quality f care issue, the pending peer review and the practitiner s right t submit additinal dcumentatin fr review by the peer cmmittee. 3 The relevant cmmittee reviews the case and makes a decisin. 4 The cmmittee s decisin is submitted t the designated Blue Crss Cmplete chief medical fficer and t Quality Management staff within 30 calendar days f the cmmittee meeting. 5 The practitiner is advised f any recmmended crrective actin/quality imprvement plan via certified letter. The practitiner may request a persnal cnference with the designated Blue Crss Cmplete chief medical fficer t discuss the plan, which may include: Medical recrd review t determine whether the identified quality issue is an islated incident r is representative f the practitiner s practice patterns Prescribed educatin activities Restrictin f new member assignment Terminatin f affiliatin 6 Blue Crss Cmplete mnitrs the results f the practitiner r independent licensed practitiner s crrective actin plan, as apprpriate. 7 Blue Crss Cmplete ntifies the practitiner r independent licensed practitiner in writing when the expectatins f the crrective actin plan have been met. 8 Additinal crrective measures, further disciplinary actin r cntract terminatin may fllw if the crrective actin plan is nt met. C. Disciplinary actin r terminatin Physician discipline r terminatin prcess When quality f care issues are severe enugh t warrant cntract terminatin rather than crrective actin, the practitiner r independent licensed practitiner terminatin prcess will be fllwed, as utlined here. Blue Crss Cmplete has an established prcedure t initiate disciplinary actin r terminatin f an affiliated practitiner r independent licensed practitiner. The cause f such actin may include but is nt limited t: Quality f care cncerns Lack f cperatin Unsatisfactry utilizatin management Behavir incnsistent with Blue Crss Cmplete managed care bjectives Failure t cmply with recredentialing standards 21

26 Evidence f fraud Exclusin r debarment frm Medicare r Medicaid participatin Other apprpriate reasns Steps in physician discipline r terminatin prcess Sectin 4: Managing the Quality f Care A practitiner may be terminated by Blue Crss Cmplete fr any reasn nt prhibited by law. Terminatin may ccur by Blue Crss Cmplete s declining t recredential an affiliated practitiner, nt renewing a time-limited cntract r ntifying the practitiner f terminatin during the term f the cntract. The frmal steps f the prcess fr terminatin relating t quality issues are: Step Actin 1 The designated Blue Crss Cmplete chief medical fficer and the Blue Crss Cmplete Quality Management staff assess the validity and seriusness f cncerns abut a practitiner s perfrmance, behavir, cnduct r attitude. Their findings are dcumented. 2 Blue Crss Cmplete ntifies the invlved practitiner f the cncern and prvides an pprtunity fr the practitiner t respnd in writing. 3 After reviewing all dcumentatin, the designated Blue Crss Cmplete chief medical fficer makes ne f the fllwing decisins: N discipline is warranted Perfrmance imprvement plan required Cmmittee review recmmended Terminatin Fr cases reviewed by cmmittees, the cmmittee makes a decisin and frwards it t the designated Blue Crss Cmplete chief medical fficer within 30 calendar days. 4 The designated Blue Crss Cmplete chief medical fficer sends a certified letter t the practitiner with a cpy f the imprvement plan r decisin. 5 Blue Crss Cmplete mnitrs cmpliance with the perfrmance imprvement plan. Nncmpliance r unsatisfactry cmpliance may result in terminatin. Expedited prcedure When Blue Crss Cmplete identifies a cncern that may jepardize member health r safety, the designated Blue Crss Cmplete chief medical fficer will intercede prmptly t assure that apprpriate care is arranged fr members. Medical bards and data bank must be ntified In accrdance with Sectin f the Insurance Cde, Blue Crss Cmplete is bligated t ntify the apprpriate state licensing bard f cases that invlve quality f care issues that will restrict r regulate a practitiner s clinical practice fr mre than 15 days. Blue Crss Cmplete is bligated t make a reprt t the Natinal Practitiner Data Bank when ne f the fllwing actins is taken based n issues related t a practitiner s quality f care: A practitiner s affiliatin is terminated A practitiner s applicatin fr affiliatin is rejected An actin is taken that results in the restrictin r regulatin f clinical practice fr a perid greater than 30 days 22

27 Additinal infrmatin abut terminatin Sectin 4: Managing the Quality f Care Blue Crss Cmplete sends written ntificatin f terminatin t the practitiner r independent licensed practitiner by certified mail. Terminatin f a practitiner fr reasns unrelated t quality f patient care is final and cannt be appealed. Terminatin f a practitiner fr reasns related t quality f patient care may be appealed. The practitiner appeal prcess is fllwed. D. Appealing physician discipline r terminatin Physicians can appeal Blue Crss Cmplete actins Blue Crss Cmplete ffers an appeal prcess fr practitiners in respnse t disciplinary actin taken r recmmended by Blue Crss Cmplete regarding the quality f their patient care. The appeal prcess is available t: All practitiners whse applicatins fr affiliatin were denied fr reasns related t quality f patient care All affiliated practitiners whse recmmended disciplinary actin includes at least ne f the fllwing: Restrictin r regulatin f a practitiner s and independent licensed practitiner s clinical practice fr mre than 15 days fr reasns related t quality f care Terminatin f a practitiner s cntract fr reasns related t quality f care The appeal prcess is a tw-level prcess. Level 1 appeal prcess The fllwing are the steps fr Level 1: St Step Actin 1 The practitiner has 30 days fllwing receipt f the written disciplinary ntice restricting the practice r terminating the cntract t file an appeal. The practitiner sends the appeal t the fllwing address: Blue Crss Cmplete P.O. Bx 5043 Suthfield, MI ATTN: Crprate Manager, Quality Management Mail Cde C330 Practitiners wh fail t request an appeal in writing within 30 calendar days fllwing receipt f the ntice waive any right t Blue Crss Cmplete s appeal prcess. 2 Blue Crss Cmplete s Clinical Quality Cmmittee reviews the appeal within 30 days f receiving the request. The practitiner r independent licensed practitiner (appealing practitiner) will be advised f the cmmittee s meeting date and his r her right t appear in persn at the appeal hearing. The cmmittee s decisin is cmmunicated t the appealing practitiner by certified letter within 60 days f the decisin. 3 Within 14 days f receiving the cmmittee s decisin, the appealing practitiner may challenge the cmmittee s decisin by making a written request fr a Level 2 appeal. 23

28 Sectin 4: Managing the Quality f Care Level 2 appeal prcess The appealing practitiner may prceed t a Level 2 appeal and request a review f Blue Crss Cmplete s decisin. The prcess is utlined as fllws: Step Actin 1 The practitiner sends a request fr a Level 2 appeal alng with any additinal infrmatin t the fllwing address: Blue Crss Cmplete P.O. Bx 5043 Suthfield, MI ATTN: Crprate Manager, Quality Management Mail Cde C330 2 The appeal is frwarded t Blue Crss Cmplete s chief medical fficer, wh reviews and makes the final decisin. 3 Within 30 days, Blue Crss Cmplete s chief medical fficer issues a written decisin t the practitiner that includes a brief descriptin f the underlying ratinale. The decisin is final. 4 Blue Crss Cmplete is bligated t ntify the apprpriate state licensing bard f cases that invlve quality f care issues that will restrict r regulate a practitiner s clinical practice fr mre than 15 days. Blue Crss Cmplete is bligated t make a reprt t the Natinal Practitiner Data Bank when ne f the fllwing actins is taken based n issues related t a practitiner s quality f care: A practitiner s affiliatin is terminated A practitiner s applicatin fr affiliatin is rejected An actin is taken that results in the restrictin r regulatin f clinical practice fr a perid greater than 30 days E. Facility nsite reviews Blue Crss Cmplete cnducts facility nsite reviews Blue Crss Cmplete will cnduct a facility site review and a medical recrd review fr all netwrk practitiners as a result f the fllwing: Member cmplaints Deficiencies identified when a site visit is being cnducted fr anther reasn, fr example, a HEDIS * review, a quality management study r audit, a disease-specific medical recrd review, r a medical recrd review audit Member surveys Reprts frm Prvider Outreach Executive inquiries Suspicin f fraud, waste and/r abuse The Blue Crss Cmplete quality management crdinatr will cntinue t mnitr the facility and/r medical recrds f the practitiner at least every six mnths, t detect deficiencies and institute actins fr imprvement until the perfrmance gals established by Blue Crss Cmplete are met. *HEDIS is a registered trademark f the Natinal Cmmittee fr Quality Assurance. 24

29 Sectin 4: Managing the Quality f Care Blue Crss Cmplete cnducts nsite reviews fr nnaccredited facilities Facility reviews are als cnducted fr nnaccredited facilities. These facilities include but are nt limited t freestanding surgical centers; hme health care agencies; hspices; nursing hmes; radiatin nclgy centers; retail clinics; skilled nursing facilities; urgent care centers; freestanding radilgy centers that cnduct CT, PET scans and MRIs; and mental health and substance abuse facilities that prvide care in inpatient, residential, utpatient r ambulatry settings. These facilities are cnsidered rganizatinal prviders. Purpse f facility nsite reviews The facility nsite review prcess ensures cnfrmity t Blue Crss Cmplete criteria fr safe and sanitary cnditins and cmplies with requirements established by Michigan s Department f Insurance and Financial Services. What Blue Crss Cmplete lks fr in a facility review Blue Crss Cmplete representatives lk fr the fllwing certificates as part f the nsite facility review: A current Clinical Labratry Imprvement Amendments certificate, if applicable Cmpliance with sterilizatin prcedures, as specified in the Blue Crss Cmplete facility review criteria A current Medical Waste Certificate Blue Crss Cmplete requires access t practitiners ffices Blue Crss Cmplete quality management representatives and authrized regulatry representatives must have access t practitiners ffices during nrmal business hurs t inspect the facility and t review and cpy member medical and mental health recrds, as required by law and as authrized by the member upn enrllment. These representatives shuld prvide identificatin upn arrival at the facility. 25

30 Sectin 5: Standards and Ratings SECTION 5: STANDARDS AND RATINGS A. Access t appintments Appintment access standards fr medical services Primary care and bstetrician-gyneclgist practitiners shuld prvide appintments t members fr medical services accrding t the guidelines in the fllwing table: 26

31 Sectin 5: Standards and Ratings Appintment type Definitin Standard Preventive care Emergency Care (Arising Suddenly and unexpectedly) Rutine primary care (symptmatic, nn-urgent) Urgent medical care (acute, symptmatic) Nn-urgent symptmatic care Cmplete histry and physical, including: Annual gyneclgic examinatins Immunizatins Other preventive care appintments Fr adults, preventive care shuld cmply with all screenings indicated in the Michigan Quality Imprvement Cnsrtium preventive care guidelines as apprpriate fr the member. Nte: The MQIC preventive care guidelines are available at mqic.rg > Current Guidelines. Fr children, preventive care shuld cmply with the Early and Peridic Screening, Diagnsis, and Treatment/Well Child Care requirements. Medical care that directly addresses threats t life, limb, r eyesight that requires immediate judgment such as: Heart attack Strke Open fractures Appendicitis Severe allergic reactin that make it difficult t breath Appintments fr members Wh were previusly seen With cnditins that are nt life threatening but that keep recurring, such as rashes and jint r muscle pain Appintments fr acute cnditins that are nt life threatening, such as: Fever ver 101 degrees Fahrenheit ver 24 hurs Persistent vmiting Mild, persistent diarrhea New-nset skin rashes Symptmatic Care: Nn-acute symptms that are nt life- r limbthreatening and nt interfering with functin. Symptms are f milder nature r lnger duratin (e.g., intermittent headaches, fatigue, clds, minr injuries, r jint/muscle pain). Within 30 business days f member s request Immediate Within 10 business days f member s request Within 48 hurs f member s request Within 7 days f member s request Specialty care Expert knwledge t ptimize treatment in unique r cmplicated curses f care. Fcuses n a particular are f care in which the prvider has extensive training and educatin. Within 6 weeks f member s request Acute specialty care Care prvided fr a nn-emergent illness r injury with acute symptms that require immediate care; examples include, but are nt limited t: Sprains, Flu symptms Minr cuts and wunds Sudden nset f stmach pain Severe, nn-reslving headache. Within 5 days f member s request 27

32 Dental health appintment access standards Sectin 5: Standards and Ratings Dental health practitiners shuld prvide appintments t members accrding t the fllwing guidelines: Dental Appintment type Emergency dental services Urgent care Definitin Requires immediate treatment in rder t save a tth, stp nging tissue bleeding r alleviate severe pain. A severe infectin r abscess in the muth can be life-threatening. Includes replacement f tth/teeth; treatment f cracked r brken tth/teeth; treats individuals wh experience acute dental pain Standard Immediately 24 hurs/day 7 days per week Within 48 hurs f member s request Rutine care Includes a prfessinal cleaning, exam and pssibly X-rays. Within 21 days f member s request Preventative services Include ral evaluatins, rutine cleaning x-rays and fluride treatments Within 6 weeks f member s request Initial appintment Within 8 weeks f member s request Evaluatin f verall health and ral hygiene, risk f tth decay, rt decay and gum r bne disease. Evaluatin f need t tth restratin r tth replacement; check bit and jaws fr prblems. Mental health appintment access standards Mental health practitiners shuld prvide appintments t members accrding t the fllwing guidelines: Mental health Appintment type Rutine mental health care Urgent mental health care Emergency mental health care: cnditins that are nt life threatening Definitin Cases in which n acute danger is detected and the member s cnditin is nt likely t wrsen significantly Cnditins that are nt life threatening, but fr which face-t-face evaluatin is necessary within a shrt perid f time (fr example, acutely wrsening symptms accmpanied by significant envirnmental change such as discntinuatin f attendance at schl r wrk). Examples: A member calls the prvider reprting she was recently discharged frm inpatient psychiatric care and is uncertain abut hw t manage current symptms and hw t transitin back t wrk and hme. A member was recently discharged frm inpatient care after a suicide attempt and calls his prvider stating he is cmpliant with medicatins but is experiencing a decrease in appetite and prblems sleeping thrugh the night. He reprts he has strng family supprt and family members are available t stay with him. He reprts being fearful f suicidal ideatin returning; he denies being actively suicidal. Cnditins that require rapid interventin t prevent deteriratin f the member s state f mind that, left untreated, culd jepardize the member s safety. Example: A member in treatment fr substance abuse calls Mnday mrning t reprt he has relapsed and binged all weekend and can t stp. He states I can t g n like this. He reprts his wife has kicked him ut f the huse and wn t let him see his children and his spnsr is away. Standard Within 10 business days f member s request Within 48 hurs f member s request Within 6 hurs f member s request 28

33 Mnitring appintment access Sectin 5: Standards and Ratings The infrmatin abut mnitring appintment access fund here applies t primary care, bstetriciangyneclgist and mental health practitiners. Blue Crss Cmplete cnducts appintment access reviews annually. Reviews are cnducted mre frequently fr practitiners wh d nt meet access standards. Blue Crss Cmplete cntacts the practitiner s ffice t determine access and recrds the next available appintment fr each f the designated appintment types. Physician-specific member cmplaints related t access are als analyzed. The expected perfrmance level fr each appintment type is 100 percent within the specified time frame. Blue Crss Cmplete prvides practitiners with a cpy f their individual access perfrmance results within fur weeks f their assessment. This may include recmmendatins fr actins fr imprvement, when applicable. Practitiner-specific access mnitring results are cnsidered at recredentialing. Blue Crss Cmplete publishes a summary f the results in the newsletters and ther publicatins. Mnitring timeliness f appintment Blue Crss Cmplete will mnitr fr cmplaints t ensure prviders ffer hurs f peratins that are n less than the hurs f peratins ffered t cmmercial enrllees r hurs f peratins are cmparable t the Medicaid Fee Fr Service, if the prvider services nly Medicaid enrllees. Cmpliance with appintment access standards If Blue Crss Cmplete determines a practitiner des nt meet appintment access standards, the nncmpliant practitiner is reassessed fr cmpliance. If cntinued nncmpliance is fund, the practitiner must submit a crrective actin plan t the Blue Crss Cmplete Quality Management department within 30 days f ntificatin. Fllw-up mnitring will ccur within 90 days. If The practitiner s crrective actin plan is apprved The crrective actin plan is nt apprved A reply is nt received within 14 days Then Blue Crss Cmplete will ntify the practitiner. Blue Crss Cmplete will request that the practitiner submit an acceptable crrective actin plan within 14 days. Blue Crss Cmplete will send a secnd letter, signed by the Blue Crss Cmplete chief medical fficer. Blue Crss Cmplete will frward cpies f the letter t the medical care grup administratr, l the Blue Crss Cmplete Prvider Netwrk Management directr and the Crprate Credentialing Department t. B. Waiting rm time Standards fr waiting rm time All Blue Crss Cmplete members shuld have apprpriate and timely access t their practitiners. The acceptable ffice waiting rm time is n mre than 30 minutes frm the scheduled time f appintment. Because situatins arise in the practice f medicine beynd the practitiner s cntrl, waiting times may extend peridically beynd the 30-minute time frame. In such cases, the member must be 29

34 Sectin 5: Standards and Ratings advised f any delay and, whenever pssible, prvided with an estimated time at which the appintment will begin. If the member is unable t wait until the practitiner is available, an alternate appintment shuld be ffered cnsistent with Blue Crss Cmplete s appintment access standards and accrding t the member s clinical status. Mnitring waiting rm time Blue Crss Cmplete mnitrs primary care physicians, mental health practitiners and ther specialists, fr cmpliance with waiting rm guidelines. C. Access t after-hurs care Standards fr access t after-hurs care All Blue Crss Cmplete members shuld have apprpriate and timely access t their practitiners. Practitiners must prvide their patients with access t care 24 hurs a day, seven days a week. Practitiner cmpliance with these standards helps t ensure that Blue Crss Cmplete members receive timely service. Achieving cmpliance with standards fr access t after-hurs care After-hurs access cmpliance can be achieved by ne f the fllwing methds: Answering service On-call pager Call frwarding t practitiner s hme r ther lcatin Recrded telephne message with instructins that direct the member t a practitiner fr instructin in after-hurs care Nte: Recrded messages instructing members t btain treatment via the emergency rm fr cnditins that are nt life threatening are nt acceptable. Mnitring access t after-hurs care On an annual basis, Blue Crss Cmplete mnitrs primary care prviders pediatrician fr access t afterhurs care by calling practitiners ffices after nrmal business hurs and dcumenting cmpliance with standards. Blue Crss Cmplete publishes a summary f the results in the newsletters and ther publicatins. Crrective actin plan required fr nncmpliance If Blue Crss Cmplete determines a practitiner des nt meet standards fr access t after-hurs care, the fllwing steps are taken: 1. A letter is sent t the nncmpliant practitiner, which indicates the practitiner must submit a crrective actin plan t the Blue Crss Cmplete Prvider Netwrk Management department within 14 days f receipt f the letter. 2. A Blue Crss Cmplete prvider accunt executive attempts t cntact the practitiner by telephne t assist in expediting submissin f the crrective actin plan. The remaining steps are utlined in the fllwing table: 30

35 Sectin 5: Standards and Ratings If The practitiner s crrective actin plan is apprved The crrective actin plan is nt apprved A reply is nt received within 14 days A reply t the secnd letter is nt received within 14 days Then The practitiner is ntified, and the ffice will be called apprximately 14 days after receipt f the crrective actin plan t reassess cmpliance with the crrective actin plan. Blue Crss Cmplete will request that the practitiner submit an acceptable crrective actin plan within 14 days. Blue Crss Cmplete will send a secnd letter, signed by the Blue Crss Cmplete chief medical fficer. Blue Crss Cmplete will frward cpies f the letter t the medical care grup administratr, l the Blue Crss Cmplete Prvider Netwrk Management directr and the Crprate Credentialing Department t. A third letter, signed by the Blue Crss Cmplete chief medical fficer, will be sent infrming the practitiner that terminatin will ccur within 60 days. D. CAHPS survey CMS mnitrs prviders thrugh the CAHPS survey CMS mnitrs health care prviders thrugh the Cnsumer Assessment f Healthcare Prviders and Systems, which is a survey randmly given t members n an annual basis. 31

36 Sectin 6: Multicultural Health Care SECTION 6: MULTICULTURAL HEALTH CARE A. Accmmdating prviders and members needs Prgram bjective The bjective f Blue Crss Cmplete s multicultural health care prgram is t ensure that health care services are delivered in ways that accmmdate the cultural and linguistic needs f Blue Crss Cmplete prviders and members. This bjective is accmplished thrugh the fllwing: Imprving the cllectin f prvider and member data Prviding access t translatin and interpretive services Reducing health care disparities Imprving health plan services Terms and definitins Prviders shuld be aware f the fllwing terms and their definitins: Cultural cmpetence: the ability f an individual t understand the scial, linguistic, mral, intellectual and behaviral characteristics f a cmmunity r ppulatin and t translate this understanding systematically t enhance the effectiveness f health care delivery t diverse ppulatins Limited English prficiency: a designatin referring t a member wh primarily cmmunicates in a language ther than English and has a limited ability t cmmunicate in English Lw literacy prficiency: In Public Law , the Natinal Literacy Act f 1991, Cngress defined literacy as an individual's ability t read, write and speak English and cmpute and slve prblems at levels f prficiency necessary t functin n the jb and in sciety, t achieve his r her gals and develp his r her knwledge and ptential. Individuals lacking these levels f prficiency wuld be cnsidered t have lw literacy prficiency. Sensry impaired: a persn wh is deaf r visually impaired B. Aspects f culturally cmpetent care Translatin services Certified translatin services are available t all Blue Crss Cmplete prviders and t eligible Blue Crss Cmplete members whse primary language may nt be English r wh have limited English prficiency r lw literacy prficiency. Prviders are encuraged t use these services t ensure all infrmatin is accurately cmmunicated t members. Members wh access care in any setting (ambulatry, utpatient r inpatient) can call Blue Crss Cmplete Custmer Service at fr assistance with any r all f the fllwing: Interpreting cnversatins with prviders r ther health care staff Translating health plan dcuments Obtaining health plan dcuments in alternative frmats Translatin and interpretive services are available in ver 200 languages. Prviders and members can call t: Obtain these services immediately ver the telephne Schedule an appintment fr services t be delivered either by telephne r in persn 32

37 Sectin 6: Multicultural Health Care Blue Crss Cmplete will prvide translatin and interpretive services after it has been verified that the physician s ffice des nt have their wn services fr their patients. After verificatin, Blue Crss Cmplete will cntact member services t cmplete a Blue Crss Cmplete Interpreter Request frm. The request shuld be cmplete within 48 hurs f services, hwever, if there is an immediate need fr a visit the request can be cmpleted as sn as pssible. TTY and TTD services are als available fr bth prviders and members wh are sensry impaired. T btain these services, prviders and members shuld call Educatin in supprt f culturally cmpetent care Health care services that are respectful f and respnsive t the health beliefs and practices and cultural and linguistic needs f diverse patient ppulatins are mre effective at imprving the quality f life f Blue Crss Cmplete members. Fr sme Blue Crss Cmplete members, language is the first barrier t health care. But alng with language barriers, the culture f different ethnic grups may influence the fllwing: An individual member s health, healing and wellness belief systems Hw a member perceives an illness r a disease and its causes The behavirs f members wh are seeking health care and their attitudes tward health care prviders T help prviders take the first step in serving diverse ppulatins the Office f Minrity Health, part f the U.S. Department f Health & Human Services, ffers the fllwing accredited cntinuing educatin prgrams: A Physician's Practical Guide t Culturally Cmpetent Care, accredited fr physicians, physician assistants and nurse practitiners. Prviders may register fr this curse at Think Cultural Health. Culturally Cmpetent Nursing Care: A Crnerstne f Caring, accredited fr nurses and scial wrkers. Prviders may register fr this curse at Office f Minrity Health. Bth prgrams ffer cntinuing educatin credits and are available nline at n cst t participants. Prviders may als visit the Think Cultural Health hme page and the Office f Minrity Health hme page fr mre infrmatin n these prgrams and fr mre resurces t enhance the cultural cmpetency f their health care practices. C. Enhancing cultural cmpetency in health care settings Reprting prvider infrmatin Blue Crss Cmplete encurages prviders and their staff t reprt their race and ethnicity and the languages they speak. This infrmatin can be reprted when prviders d their attestatin thrugh the Cuncil fr Affrdable Quality Healthcare, r CAQH. Prvider and member infrmatin is analyzed t identify pprtunities fr imprvement s Blue Crss Cmplete can prvide the best pssible service t its prviders and members. The languages reprted by prviders are published in the prvider directry s members can easily find prviders wh speak their language. 33

38 Sectin 6: Multicultural Health Care Additinal resurces The fllwing additinal resurces are available: HHS Health Resurces and Services Administratin: Culture, Language Health Literacy Natinal Institutes f Health: Clear Cmmunicatin / Cultural Cmpetency Health Literacy Innvatins TM The Health Literacy & Plain Language Resurce Guide 34

39 Sectin 7: Member Eligibility SECTION 7: MEMBER ELIGIBILITY A. Membership ID cards Medicaid ID card All Blue Crss Cmplete members are enrlled in either the Healthy Michigan Plan r in anther Michigan Medicaid plan. They, alng with ther Medicaid beneficiaries, receive a state-issued Medicaid ID card, after their eligibility is determined by the Michigan Department f Human Services. Nte: Eligibility fr Medicaid is determined by the Michigan Department f Human Services. The administratin f the Medicaid managed care prgrams is carried ut by the Michigan Department f Health and Human Services. The Medicaid ID card is als knwn as the mihealth card. Additinal infrmatin n the mihealth card is available in the March 2014 issue f Cmplete Update. Medicaid Beneficiary ID number The Medicaid ID card includes a unique Medicaid Beneficiary ID number fr the individual identified n the card. This number identifies the individual as eligible fr Medicaid and may be used by prviders t verify eligibility with the state f Michigan, via the magnetic stripe that prviders can swipe. 35

40 Sectin 7: Member Eligibility Medicaid Beneficiary ID numbers are 10 digits, in line with the Michigan Department f Human Services system knwn as Bridges. Blue Crss Cmplete member ID card Each Blue Crss Cmplete member als receives a Blue Crss Cmplete member ID card, as fllws: Members enrlled in the Healthy Michigan Plan receive a Blue Crss Cmplete member ID card with Healthy Michigan Plan dental services infrmatin n the back f the card. Healthy Michigan Plan ID cards issued starting May 1, 2015, als shw the Healthy Michigan Plan label n the frnt f the card. Nte: Fr Healthy Michigan Plan members enrlled prir t May 1, 2015, the Healthy Michigan Plan label is nt shwn n the frnt f the card, but prviders can lk fr the Healthy Michigan Plan dental services infrmatin n the back f the card. Other members receive a standard Blue Crss Cmplete member ID card. Each Blue Crss Cmplete member ID card shws: The member s name The member s Blue Crss Cmplete ID number (a de-identified cntract number) The member s Medicaid Beneficiary ID number A phne number the member can call fr mental health care The pharmacy BIN and PCN numbers, t facilitate prescriptin claims prcessing Prviders shuld use the member s Blue Crss Cmplete de-identified cntract number t verify Blue Crss Cmplete eligibility and t submit claims. T verify member eligibility with the state f Michigan, as required, prviders shuld use the Medicaid Beneficiary ID number, which is als lcated n the frnt f the Blue Crss Cmplete member ID card. Pssessin f the Blue Crss Cmplete member card cnfers n right fr benefits under this Certificate. T be entitled t such benefits, the hlder f the card must meet and maintain all MDHHS requirements. If a member permits the use f his r her member ID card by any ther persn, the card may be reclaimed by Blue Crss Cmplete r its prviders, and all rights f that member and ther members f his r her family can be terminated immediately. A member must reprt lss r theft f the member ID card t Blue Crss Cmplete immediately upn discvery f the lss r theft. 36

41 Sectin 7: Member Eligibility Blue Crss Cmplete member ID card: Standard card N. Explanatin 1 Enrllee Name: Each member gets an ID card in his r her wn name. 2 Enrllee ID: Prviders shuld use this number, the member s de-identified Blue Crss Cmplete cntract number, t check eligibility. The Blue Crss Cmplete cntract number begins with the XYU cde. 3 Issuer ID number: This number identifies which plan issued the card. 4 Medicaid Beneficiary ID: This is a number issued by the state f Michigan that identifies the member as eligible fr Medicaid. Prviders may use this number t verify eligibility with the state f Michigan. 5 Grup Number: The Blue Crss Cmplete grup number 6 Pharmacy infrmatin: Prescriptin drug cverage under Blue Crss Cmplete 7 Magnetic stripe: In the future, this stripe will allw the prvider t swipe the card and view eligibility and benefit infrmatin n the cmputer. Nte: The ID card readers are nt yet available. 37

42 Blue Crss Cmplete member ID card: Healthy Michigan Plan Sectin 7: Member Eligibility N. Explanatin 1 Enrllee Name: Each member gets an ID card in his r her wn name. 2 Enrllee ID: Prviders shuld use this number, the member s de-identified Blue Crss Cmplete cntract number, t check eligibility. The Blue Crss Cmplete cntract number begins with the XYU cde. 3 Issuer ID number: This number identifies which plan issued the card. 4 Medicaid Beneficiary ID: This is a number issued by the state f Michigan that identifies the member as eligible fr Medicaid. Prviders may use this number t verify eligibility with the state f Michigan. 5 Grup Number: The Blue Crss Cmplete grup number 6 The Healthy Michigan Plan label appears n the frnt f ID cards issued starting May 1, Pharmacy infrmatin: Prescriptin drug cverage under Blue Crss Cmplete 8 Magnetic stripe: In the future, this stripe will allw the prvider t swipe the card and view eligibility and benefit infrmatin n the cmputer. Nte: The ID card readers are nt yet available. 9 Phne number fr dental cverage: Blue Crss Cmplete members enrlled thrugh the Healthy Michigan Plan have dental cverage. 38